Emergency Medicine and the Future of Mobile Health in Lebanon

Andrew LS Thornton

Introduction

The Lebanese government currently lacks legislation to fund prehospital emergency medical services.[1] The bulk of the responsibility for supplying these services falls to humanitarian organizations, chiefly the Lebanese Red Cross (LRC). The LRC and other agencies operate largely as a result of grants and donations from non-governmental organizations (NGOs), as well as the service and commitment of their volunteers.[2] While donations have kept these groups afloat, their reliance on competitive funds and charitable acts creates a fragile situation for the Lebanese people. Without sufficient economic support, the Lebanese government and these humanitarian organizations constantly struggle to deliver sufficient prehospital emergency medical services. Developing a new system through cooperation and collaboration with regional and international powers would prove to strengthen and secure a promising future for prehospital emergency medicine in Lebanon. Although political hurdles impede progress in this domain, there is much potential for Lebanon to construct an efficient and capable system.

This paper addresses the following questions: Why does the Lebanese government primarily rely on volunteers for prehospital emergency medicine services and what problems does this create that need to be addressed?

The Lebanese government tacitly relies upon the incomplete prehospital emergency medical services of humanitarian organizations and their volunteers as a result of its dependence on these services in the Lebanese Civil War. It has since made little progress in acknowledging and addressing the need for change. The question of precisely why there has been no centralized, government-directed system of response is beyond the scope of this paper, lying perhaps more properly in the field of political science. It is worth noting that the fractious history of Lebanon itself could provide clues to the origin of this puzzle, but this is, again, a topic for a different discussion. The primary issues within the current context that need to be addressed are the current critical shortfalls in Lebanon’s prehospital emergency medical system, its division and disorganization, and its ultimate need for regulation. Since the Lebanese Civil War, political and cultural realities have delayed progress in the medical arena (as well as many others), resulting in further national crises such as the Lebanese Waste Crisis. Secondarily and critically, this paper will illustrate that the government’s dependence on humanitarian organizations to maintain the stability of its frontline of healthcare is a radical pitfall for the future development of Lebanese society.

Background

As defined by the National Institutes of Health, prehospital emergency medical services encompass the totality of the aid provided from the scene of a disaster until the patient is delivered to a hospital.[3] In Lebanon, NGOs provide the majority of the country’s prehospital emergency medical services. The largest of these providers and the focus of this paper is the LRC. The LRC exists as a branch of the International Red Cross and Red Crescent Societies, and it has served as the country’s officially delegated agency since 1964.[4] Despite this delegation, Lebanese legislation does not recognize the LRC or any other agency as the leader of Lebanon’s prehospital emergency medical services. The LRC and the government agency Civil Defense provide roughly 98% of Lebanon’s prehospital emergency transports, and although Civil Defense is government-run and tasked with providing these services, it only carries out 28% of these transports while the volunteer-led LRC covers 70%. Civil Defense is followed by many smaller organizations, themselves funded by a myriad of for-profit companies as well as religious, political, social, and charitable groups that account for the rest of the emergency prehospital care provided in Lebanon.[5],[6] Troublingly, despite the array of organizations working to provide care, few of them actually offer any medical assessments or treatment and only supply transportation from the place of the emergency to the hospital.

The Lebanese Civil War (1975-1990) radically shook the field of prehospital emergency medicine, and there have been virtually no further modifications since that conflict. During the Civil War, the needs of the country far exceeded its resources, and prehospital emergency medical service providers were forced to accommodate for the flood of patients with more severe wounds. To combat the shortage of available prehospital providers and scarcity of ambulances, agencies implemented a completely new tactic:  patients no longer received medical care in the ambulance, freeing the volunteers and ambulances to return to the field and bring in more casualties. The trade-off for this loss of care during patient transport was a dramatic reduction in the time it took to deliver patients to the hospital.[7] While this reduction in delivery time was helpful and necessary during the Civil War, lack of care during transport became a permanent aspect of  Lebanon’s prehospital emergency medical system. Almost thirty years later, the same system of rapid delivery and neglect for medical attention continues. Lebanon faces a number of critical threats: a lack of medical attention in prehospital care , a scarcity of ambulances, as well as the dearth of education regarding emergency medical services in Lebanon. As a result of these factors, 80% of critical cases are transported to hospitals by way of private vehicles, rather than ambulances.(Sayed, 2012)

Critical Shortfalls

Paradoxically, hostile conditions have contributed not just to setbacks, but advances for medicine in Lebanon as well. During the war, changes to prehospital emergency medical services placed all medical responsibilities in the hands of the hospitals. Despite virtually denying immediate care to seriously injured or ill patients, the flood of critical cases afforded Lebanese doctors irreplaceable experience with severe war wounds. Through their valuable insights and increased understanding of conflict medicine, Lebanese doctors are better equipped than ever before. As a direct result of encountering such critical cases during the Civil War, they are able to educate the following generations of physicians about treating such conditions.[8] One permanent result of this development is the American University of Beirut’s Conflict Medicine Program. Defining a new field, this innovative program is a response to war’s ever-changing ecologies.[9] This progress has come at a tragically high price, though. While organizations providing prehospital emergency medical services made adjustments throughout the Civil War, they have shown a collective inability to effectively respond to Lebanon’s needs during and after a disaster. Nevertheless, Lebanon continues to lean on this incapable system.[10]

Moving away from the transportation techniques adopted during the Civil War while holding on to the innovative treatments developed since then could prove to increase success in handling these critical cases. Unfortunately, there are currently no standards for medical oversight, meaning that medical treatment protocols during patient transport vary among agencies. Moreover, many agencies limit themselves to providing the absolute basic treatments: first aid, cardiopulmonary resuscitation (CPR), and automated external defibrillators (AED) when available.[11] Increased medical oversight and physician involvement is necessary to improve prehospital emergency medicine in Lebanon.17

Division and Disorganization

Lebanon’s prehospital emergency medical system is stressed in part by the unpredictability of volunteers, and many of its critical shortfalls result from a lack of regulation. As described in the introduction, there are a number of agencies that try to provide prehospital emergency medical services throughout the country; however, they do not function at the same level because of the absence of a regulating body.  Consequently, the standards to which each agency is held varies widely throughout the country, leaving medical supervision – viewed as a luxury rather than a necessity – languishing by the wayside. The majority of these agencies function through the participation of volunteers, and while these volunteers offer invaluable time and labor, there are many concerning issues that come with the prevalence of volunteers in an unregulated prehospital emergency medical system.[12] Professionalism, commitment, continuity, and availability all come into question.[13] Generally, volunteer providers and ambulance drivers receive only basic training and oftentimes do nothing other than transport the patients. They are rarely given paramedical training or even taught proper patient transportation practices.

While these agencies provide the majority of prehospital emergency medical services, their locations are unequally distributed throughout the country, pointing to social and economic inequities. The Civil War played a fundamental role in the geographical expansion of medical care throughout the country. Road blockages and divided territories led to the establishment of new medical centers outside of the capitol – an uncommon occurrence at the time. Along with new experience in treating traumatic injuries, these new medical centers served the population and improved health outcomes. After the Civil War, however, just as abbreviated procedures for patient transfer continued, so did the establishment of the new medical centers, and because certificates of need do not exist in Lebanon, private companies continued to build medical hubs.[14] Many poor regions in Lebanon remained without access to care while more wealthy areas saw continued expansion. Proper prehospital emergency medical care remains inaccessible in many parts of the country, and the free market economy will continue to drive this trend forward unless there is intervention.[15]

There is not enough money for prehospital care, the supply of money is unstable and unpredictable, and it is distributed unequally. This unequal distribution is a result of many other factors as well: the LRC (entirely) and Civil Defense (in part) depend financially on Lebanese governmental agencies such as the Ministry of Health, on other countries, and on national and international NGOs. As the country’s largest provider of prehospital emergency medical care, the LRC functions only as a result of the scattered funding that it receives, which is inconsistent at best.[16] While some money is put aside for the LRC by the Ministry of Health, this funding generally comes in the form of grants and is not promised for the future, so the LRC relies on donations of equipment such as ambulances and emergency gear, in addition to supplementary grants to provide the very basic training that their volunteers do receive.

Lebanon needs a planned, funded, centralized system of delivering prehospital care, but political fractures and social inequalities leave the nation relying on unpredictable gifts. The reliance on donations puts the LRC and other prehospital emergency medical agencies at the mercy of charity. Without a centralized system, the division and disorganization that exists in Lebanon’s prehospital emergency medical system will continue to result in the inefficient use of funds and equipment, confusion within the population, and ultimately worse health outcomes. Examples of this dependence on a national scale are grants and equipment donations from the Kuwaiti, French, and Italian governments in 1996, 1999, and 2000, respectively.[17] These contributions funded research and development carried out by the Ministry of Health for the purpose of creating a new prehospital emergency medical system, provided ambulances and other equipment, and offered support for additional analyses. Despite these donations, the government has struggled to make use of the resources that it gained. Ten years after the last of these donations were made, none of the completed studies had been implemented.24 In addition to extended delays in executing these funded research projects, the equipment that these countries donated went almost completely unused. A portion of the 2000 donation from Italy went towards the establishment of an emergency training center, and while the ministry went as far as to build the infrastructure, it was not until seven years after its establishment that the ministry first utilized this new wealth of resources.[18]       

Need for Regulation

The current prehospital emergency medical system in Lebanon is characterized by a lack of collaboration between government agencies, such as the Ministry of Health, and non-government agencies such as the LRC.[19] Regulation and unification of agencies that provide prehospital emergency medical services in Lebanon is the key to increasing efficiency, simplifying access to emergency care, and better health outcomes. The predictable provision of funds will offer opportunity for both the provider and the recipient to direct the future of the system. For reasons that remain unclear, legislation in Lebanon does not currently reserve any funding specifically for emergency prehospital care; consequently, the Ministry of Health and the Lebanese government have little influence on the system’s future.[20] To properly protect and provide for the country, however, it is critical that the government take action in allocating resources specifically for this system. While many political and cultural obstacles currently exist,  the development of a centralized agency is necessary, and it would create the first-ever opportunity to pool funds and other resources, appropriately redistribute emergency centers, and untangle the confusion surrounding how to access necessary services.[21]

Creating a centralized system is the only way to ensure that the needs of the country are sufficiently accounted for; furthermore, only a centralized system could then be held accountable for efficiently responding to the assessed need. This structure would have the potential to minimize overlap that currently contributes to the waste of resources (time, property, equipment, etc.), as well as the potential to begin the construction of an equitable distribution of emergency centers throughout the country.

Fragility and Vulnerability

Lebanon’s dependence on humanitarian organizations and volunteers reveals a vulnerability in its ability to care for its citizens in the case of a national emergency.[22] The majority of the labor force necessary to operate and maintain the country’s current system is comprised of volunteers; however, should a disaster (natural or man-made, internal or international) strike, the question as to what portion of that volunteer population would be willing or even able to continue serving will arise. This limitation would leave the country unable to adequately respond to a national emergency, particularly because of shorthanded prehospital emergency medical agencies and their inability to provide ample care without a steady supply of trained personnel.

In response to the Civil War, procedures changed dramatically to accommodate the hostile conditions and soaring rates of traumatic injury.[23] While the modifications made during that time allowed for escalated patient intake, these procedures neglected the patients’ immediate needs. Left practically untouched for thirty years, these procedures continue to be inadequate. If the system remains unchanged, a national emergency will result in dependence on unreliable foreign aid and, ultimately, worse health outcomes for the Lebanese people. Increased governmental funding is critical to the establishment of a new, self-sufficient system that is anchored by adequately compensated and well-trained prehospital emergency medical care providers.

Conclusion

Despite the evident need for funding the establishment of a centralized prehospital emergency medical system, the Lebanese government has failed to address these pressing problems and, consequently, has positioned itself to depend on outside groups for aid in the event of a national emergency. Until a centralized system is established and appropriately funded, there will not be a comprehensive structure of adequate training, licensure, and education – the three principal criteria for the delivery of sustainable care.[24] The lack of formal funding and the overdependence on donor assistance results in the system’s inability to establish new standards and even threatens to deconstruct the current organization of health care delivery. Maintaining the stability of the frontline of healthcare is vital to Lebanon’s resilience in the face of a national emergency. Despite historical negligence of these issues from the government, there is hope for improvement through examination of and response to the three issues that demand attention: the critical shortfalls in Lebanon’s prehospital emergency medical system, entrenched division and disorganization, and clear need for regulation.

National efforts to tackle these issues have come and gone, demonstrating the need for urgency.[25] Seemingly intangible political and cultural obstacles inhibit progress in this arena, and as a result, a national prehospital committee has been in the conceptual stages for over ten years now. [26] Currently, many groups are working individually to extend their reach and increase the quality of care that they can deliver. The LRC is introducing new training courses for its volunteers and those of a select group of other providers in Lebanon, thanks to a grant from an international ally. Further research could analyze the ways in which influential institutions such as the American University of Beirut may contribute to these efforts, and while dependence on other countries for assistance may expose Lebanon’s current limitations, partnering officially and reliably through diplomatic channels with nearby nations could prove to be momentous with respect to sustainability of the system as well as with regard to international relations.[27] Iraq and Jordan stand as excellent candidates for comparison and collaboration with Lebanon, as they stand as neighbors that have shown the ability to improve their prehospital emergency medical systems after conflict.[28] While political hurdles impede progress in this domain, there is much potential for Lebanon to construct an efficient and capable system, and it is essential that this be done as soon as possible.

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El Sayed, Mazen J, and Jamil D Bayram. “Prehospital Emergency Medical Services in Lebanon: Overview and Prospects.” Prehospital and Disaster Medicine, vol. 28, no. 02, 20 Dec. 2012, pp. 163–165., doi:10.1017/s1049023x12001732.

Ghossain, Antoine, et al. “Surgery in Lebanon.” JAMA Surgery, vol. 138, Feb. 2003, pp. 215–219., doi:10.1001/archsurg.138.2.215.

Hitti, Eveline. “Left Without Being Seen in a Tertiary Care Hospital Emergency Department in Lebanon.” The Journal of Emergency Medicine, vol. 56, no. 1, Jan. 2019, pp. 126–127., doi:10.1016/j.jemermed.2018.11.021.                  

Jamil, Bayram D. “Emergency Medicine in Lebanon: Overview and Prospects.” The Journal of Emergency Medicine, vol. 32, no. 2, 27 June 2006, pp. 217–222., doi:10.1016/j.jemermed.2006.12.007.

Kronfol, N.M., Rebuilding of the Lebanese health care system: health care sector reforms. East Mediterranean Health Journal 2006;12(3-4):459-473

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Viswanathan, Kristin, et al. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. National Academies Press, 2012.

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[1] El Sayed, Mazen J, and Jamil D Bayram. “Prehospital Emergency Medical Services in Lebanon: Overview and Prospects.” Prehospital and Disaster Medicine, vol. 28, no. 02, 20 Dec. 2012, pp. 163–165., doi:10.1017/s1049023x12001732.

[2] Moucharafieh, Ramzi, and Rayana Bu-Haka. “Development of Emergency Medicine in Lebanon.” Annals of Emergency Medicine, vol. 28, no. 1, 1996, pp. 82–86., doi:10.1016/s0196-0644(96)70141-5. 

[3] Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations. “Prehospital Care Emergency Medical Services (EMS).” Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response., U.S. National Library of Medicine, 21 Mar. 2012, www.ncbi.nlm.nih.gov/books/NBK201058/.

[4] “Lebanese Red Cross: Emergency Medical Services.” Lebanese Red Cross, www.redcross.org.lb/SubPage.aspx?pageid=161

[5] Jamil, Bayram D. “Emergency Medicine in Lebanon: Overview and Prospects.” The Journal of Emergency Medicine, vol. 32, no. 2, 27 June 2006, pp. 217–222., doi:10.1016/j.jemermed.2006.12.007.

[6] Kronfol, N.M., Rebuilding of the Lebanese health care system: health care sector reforms. East Mediterranean Health Journal 2006;12(3-4):459-473 

[7] Pane GA. Emergency Medical Services System: Assessment and Recommendations. World Bank- Health Sector Rehabilitation Project; 1999:1-7.

[8] Moucharafieh, Ramzi, and Rayana Bu-Haka. “Development of Emergency Medicine in Lebanon.” Annals of Emergency Medicine, vol. 28, no. 1, 1996, pp. 82–86., doi:10.1016/s0196-0644(96)70141-5.

[9] Saleh, Shadi. American University of Beirut Global Health Institute: A Component of the HEALTH 2025 Vision. 2018, www.cugh.org/sites/default/files/04%20CS_10%20Menaza.pdf.

[10] Ghossain, Antoine, et al. “Surgery in Lebanon.” JAMA Surgery, vol. 138, Feb. 2003, pp. 215–219., doi:10.1001/archsurg.138.2.215.

[11] El Sayed, Mazen J, and Jamil D Bayram. “Prehospital Emergency Medical Services in Lebanon: Overview and Prospects.” Prehospital and Disaster Medicine, vol. 28, no. 02, 20 Dec. 2012, pp. 163–165., doi:10.1017/s1049023x12001732.

[12] Jamil, Bayram D. “Emergency Medicine in Lebanon: Overview and Prospects.” The Journal of Emergency Medicine, vol. 32, no. 2, 27 June 2006, pp. 217–222., doi:10.1016/j.jemermed.2006.12.007.

[13] Moucharafieh, Ramzi, and Rayana Bu-Haka. “Development of Emergency Medicine in Lebanon.” Annals of Emergency Medicine, vol. 28, no. 1, 1996, pp. 82–86., doi:10.1016/s0196-0644(96)70141-5.

[14] A Certificate of need is a statement issued by the government for proposed construction of a health facility that ensures that the facility will be needed at the time of its completion.

[15] Ghossain, Antoine, et al. “Surgery in Lebanon.” JAMA Surgery, vol. 138, Feb. 2003, pp. 215–219., doi:10.1001/archsurg.138.2.215.

[16] Jamil, Bayram D. “Emergency Medicine in Lebanon: Overview and Prospects.” The Journal of Emergency Medicine, vol. 32, no. 2, 27 June 2006, pp. 217–222., doi:10.1016/j.jemermed.2006.12.007.

[17] Zied I, Abu Dubai H Emergency Medical Services in South Lebanon (Thesis). Sidon, Lebanon. Lebanese University Nursing School; 2001:59-65

[18] Jamil, Bayram D. “Emergency Medicine in Lebanon: Overview and Prospects.” The Journal of Emergency Medicine, vol. 32, no. 2, 27 June 2006, pp. 217–222., doi:10.1016/j.jemermed.2006.12.007.

[19] Ocallaghan, Sorcha, and Leslie Leach. “The Relevance of the Fundamental Principles to Operations: Learning from Lebanon.” International Review of the Red Cross, vol. 95, no. 890, 2014, pp. 287–307., doi:10.1017/s1816383114000228.

[20] El Sayed, Mazen J, and Jamil D Bayram. “Prehospital Emergency Medical Services in Lebanon: Overview and Prospects.” Prehospital and Disaster Medicine, vol. 28, no. 02, 20 Dec. 2012, pp. 163–165., doi:10.1017/s1049023x12001732.

[21] Moucharafieh, Ramzi, and Rayana Bu-Haka. “Development of Emergency Medicine in Lebanon.” Annals of Emergency Medicine, vol. 28, no. 1, 1996, pp. 82–86., doi:10.1016/s0196-0644(96)70141-5.

[22] Viswanathan, Kristin, et al. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. National Academies Press, 2012.

[23] Ghossain, Antoine, et al. “Surgery in Lebanon.” JAMA Surgery, vol. 138, Feb. 2003, pp. 215–219., doi:10.1001/archsurg.138.2.215.

[24] El Sayed, Mazen J, and Jamil D Bayram. “Prehospital Emergency Medical Services in Lebanon: Overview and Prospects.” Prehospital and Disaster Medicine, vol. 28, no. 02, 20 Dec. 2012, pp. 163–165., doi:10.1017/s1049023x12001732.

[25]  Jamil, Bayram D. “Emergency Medicine in Lebanon: Overview and Prospects.” The Journal of Emergency Medicine, vol. 32, no. 2, 27 June 2006, pp. 217–222., doi:10.1016/j.jemermed.2006.12.007.

[26] El Sayed, Mazen J, and Jamil D Bayram. “Prehospital Emergency Medical Services in Lebanon: Overview and Prospects.” Prehospital and Disaster Medicine, vol. 28, no. 02, 20 Dec. 2012, pp. 163–165., doi:10.1017/s1049023x12001732.

[27] Zaatari, Ghazi S. Pathology and Laboratory Medicine at the American University of Beirut 1866-2015. American University of Beirut, 2015.

[28] VanRooyen, Michael. “International Emergency Medical Services: Assessment of Developing Prehospital Systems Abroad.” The Journal of Emergency Medicine, Elsevier, 9 July 1999, www.sciencedirect.com/science/article/pii/S0736467999000657.